MEDICARE: KIM JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1689269243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM JACKSON

Provider Business Mailing Address
First Line	:	1264 NEWMANTOWN RD
Second Line	:
City	:	GROVETOWN
State	:	GA
Zip	:	30813-3610
Country	:	US
Telephone Number	:	706-833-6879
Fax Number	:

Provider Business Practice Location Address
First Line	:	1264 NEWMANTOWN RD
Second Line	:
City	:	GROVETOWN
State	:	GA
Zip	:	30813-3610
Country	:	US
Telephone Number	:	706-833-6879
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	03/05/2021

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Directions to “ KIM JACKSON ” Practice Location

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